Friday, June 29, 2012

The Expert Practice Of Medicine

Some people practice for the fortune.  They think expensive houses and flashey cars will quench the inner flames of  insecurity.  Some people practice for the fame.  They toss around the title doctor as if it is the answer to a question that no one bothered to ask. 

I don't know why I became a physician.  I remember some vague notion about helping people, but many professions offer such opportunities without so much personal cost.

Growing up with a learning disability, success was rare and often earned long after the sweat had been wiped from my brow and the creases in my forehead had unfurled.  I remember the feeling of inferiority.  I remember the hours of hard work bent over with pen in hand and paper muddled with eraser marks.

We are products of our own dysfunction.  What better field to pursure for a child continously bucking up against the heals of his peers.  As the years passed, my endurance grew, and I learned to sprint out of those chains that embraced me.

Yet, even today, I am still a little boy pushing up against a puzzle that requires faculties far above my means.

There is no challenge greater than the expert practice of medicine.  There are no equations as complex as human pathophysiology.

True empathy requires a daunting reserve of emotional inteligence.

No matter how exhausted I am at the end of each marathon of a work day,

I can't help but still feel an all encompassing sense of awe.

Thursday, June 28, 2012

Wisdom And Context

There is knowledge.  Practiced by smart looking physicians in pressed pants and starched button down shirts.  They scurry through hospitals and clinics with an air of sophistication and an all knowing attitude. This behavior is learned through years of studying, learning, forgetting, and then learning once again.  There is a misguided tendency to worship at the altar of this impotent mistress.  Education never cured the ailing mind nor heart, much less the body.

As I wander down this zig-zagging path, I find myself much less enamored by knowledge.  One only has to search out the right stone to look under.  Yet I stumble over and over again on patient care.  What has been gained in comprehension takes a back seat to something far more important and difficult to decipher.


Like a blind man, I have searched for it with my hands, grazing the indentations but unschooled in the markings of braile. Like a deaf man, I have stared wisdom in the face but have been unable to read her mesmerizing lips.  I have tried to taste without a sense of smell.

My books have no power here.

As of late, I have begun to search for wisdom in the exam room. Who better to learn from than the octagenerian lawyer, or the middle aged playwright.  With the deepening of conversation the patient loses the disease moniker.   They become more defined by who they are and less by what is wrong with them.

I have now started to understand the person, and it has made all the difference.

Knowledge is an algorithm.

Wisdom is context.

Tuesday, June 26, 2012

Face Time

Most accountants don't photo copy tax returns.  They don't stuff envelopes.  They rarely waste time sitting at the front desk answering phones like a secretary.  Most lawyers don't do the office faxing.  You rarely see them sweeping the floor or cleaning the company bathroom.  I guarantee the CEO of United Healthcare doesn't make cold calls to sell insurance.

The reasons are simple and self explanatory.  You don't waste the time of the most educated and valued assets of the company doing busy work.  Accountants account.  Lawyers lawyer.  And CEO's do something important although I'm at a loss to describe exactly what!  Most non revenue generating activities are pawned off on less trained, less well paid employees.

These are the facts of running a successful business.

And like other entrepreneurs, physicians have traditionally followed the same coarse.  Go back a few decades, and physicians spent the majority of their day doctoring.  They didn't waste time on extensive charting-they scribbled a few illegible lines.  They didn't eprescribe or fill out face to face encounters, the girl (or guy) at the front desk did the more mundane activities. 

Paperwork was scant.  Distractions were minimal.  Medicine was practiced.

In steps the government.  Starting with the enactment of medicare and ending with the new meaningful use criteria, the landscape has drastically changed.  Face time between physician and patient is dwindling.  Instead we stare down the barrel of countless forms or sit mesmerized in front of computer screens.

For every patient encounter there is an everproliferating mass of physician specific clerical work.  Admission med reconciliation, discharge med reconciliation, Face to Face encounter, discharge instructions, med authorization, radiology utilization, eprescribe, auto fax.  Need I say more?

We have become highly trained, poorly paid secretaries. 

If you are sitting in your physicians waiting room and a fellow patient falls down in front of you having a cardiac arrest, run quickly through the doors.  Bypass the exam rooms because your doctor won't be there.  Most likely he'll be sitting in his office,

filling out some dumb form.

Monday, June 25, 2012

How Does This Make You Feel? An Exercise In Creative Writing

Black screen.

The silence is broken by the deep voice of the Narrator.  The words are crisp but spoken quickly and in a slightly loudish tone.  One gets the feeling that he is angry.

What happens when a life is terminated prematurely?

The picture explodes on the screen inducing the viewer to squint.  Obnoxiously bright light reflects off the pavement.  The protagonist is lying with his back to the ground and his arms open at his sides.  He appears to be in his twenties.  His hair is cropped and his body's muscular contour vaguely shows underneath his clothes.  His eyes are open and staring up and to the right.  He has a pinstripe shirt and tie tucked into tailored pants.  He wears a short white lab coat that ends at his waist.

As the camera moves in closer the viewer notices the lack of movement.  Is this a snapshot or video?  Footsteps are heard running back and forth in the distance. A trickle of blood breaks the stillness as the face comes into clearer view.  The blood wends its way down the suffocatingly pale contour.  Its origin from an undefinable position on the forehead.  It passes the chin and stains the collar before dribbling onto a name tag hanging from the shirt pocket. 

The blood passes an ordinary nondescript name and stops at the words:

Medical Student

The screen goes black.

Cue snapshots.  Each picture to remain on the screen for thirty seconds, enough time for the viewer to note the detail.

Still Life 1

The protagonist is a few years older.  His countenance is gruff and bears a few days of facial hair.  He wears a gown and is standing next to a physician in scrubs and a face mask.  A nurse stands by closely with a newborn baby in hand. 

The physician has placed one arm around the protagonist's shoulder.  It is clear that they are more than just doctor and patient.  With the other hand he holds the umbilical cord in a hemostat.

At the edge of the screen the viewer can barely make out the uncovered feet and ankles of the mother still resting in stirrups.  The protagonist holds a pair of scissors comfortably in his hand.  He is smiling.

The screen goes black.

Still Life 2

The protagonist's face has aged.  Wrinkle lines are noticeable on the cheeks and adjacent to the eyes.  He is shaking hands with a rather obese man in a suit.  Maybe a politician.  They are standing outside a newly remodeled building.  A sign on the front reads "Free Clinic" in over sized letters.

There is a crowd surrounding the two men.  Many of them are smiling.  Towards the edges of the gathering is a child in a wheel chair. She looks on quizzically.  She has been told that this is an important day but she doesn't know why.

Many participants are dressed in designer clothing. But not all.  Some wear the badge of poverty proudly and stand tall on this unique day. 

The screen goes black.

Still Life 3

Our friend is now gray and balding.  He sits in a room filled with machines and monitors.  His chair is pulled up against a bed uncomfortably, and he is leaning over to hold the hand of a lifeless body lying next to him.  Her face is obstructed by the plastic tubing sprouting out of her mouth.  He is looking gently into her eyes and perhaps whispering something into her ear.  His body is bent forward and the viewer is just barley able to make out the word "emeritus" inscribed in cursive on his long white lab coat.

Behind the protagonist stands a group of youngish looking men and women.  Some with long and others with short coats.  A few are watching the scene intently.  One is flipping through an IPad.  Another is holding his pager up to his eyes and squinting.

Past the glass doors of the room one can make out small details of a bustling nursing station.  There is a sense of hurry and continuous motion.

The screen goes black.

Still Life 4

The protagonist is now elderly.  He must be at least in his eighth decade.  He is lying in a hospital bed with his eyes closed.  A telemetry monitor above him shows a flat line going across the screen.  Ten people of different ages and sizes sit or stand around the room.  A small girl rests on her mother's lap and curls into her arms.

The setting is serene.  The expressions around the room are of both sadness and exaltation.  The protagonist is deadly still, much like in the opening scene.

As one looks over to the door of the room, they are surprised to see multiple faces peering in.  Doctors, nurses, orderlies are standing together silently and looking on.

Fade to black.

The voice of the Narrator now returns but softer, slower.

What happens when a life is terminated prematurely?

We all lose something.

The screen remains black.

Cue music.

Sunday, June 24, 2012

Our Profession

I never said I don't get burned out.  So when Zara's mother called on Saturday afternoon, I have to admit that I wasn't in the best of moods.  I strained to remain patient as I listened to the scared voice on the other end of the phone line.  I was tired.  I had already made the forty five minute trip to the hospital twice that morning.  It was the end of a long week, in  along month, nestled in a tiring year.  Come hell or high water, I couldn't imagine getting back in my car.

Zara was not your typical twenty five year old.  Hampered by both real and imagined intestinal problems, it seemed that rarely a weekend went by that I was not on the phone with her mother.  Her provisional diagnosis of irritable bowel syndrome was occasionally interrupted by more readily diagnosable pathology such as diverticulitis.

This time, the pain was more severe than usual and nestled in the right lower quadrant.  I directed her mother to take her to the ER and then hung up the phone.  Then I let fly as series of foul mouthed curses.  Luckily my children were in the other room.

A few hours later when I got the call from the emergency room, I was nonplussed.  The cat scan had not been done.  I crabbed at the ER doc, crabbed at the admitting nurse, and crabbed at the CT tech.  It was only after I got off the phone, that I realized how angry I had been over the last few months.

After dinner, I kissed my children good night and mentally prepared for the long drive.  Zara had appendicitis.  An hour later, I walked into her room and greeted her mother.  The poor woman's face clearly showed the fatigue and strain over tending to a sickly child.  She grabbed  my hand and smiled.  The muscles in her brow relaxed, and for a moment she looked years younger.  She spoke to her daughter who was lying in the bed behind her as she looked into my eyes.

Everything will be OK, Dr. Grumet is here.

Instantaneously, I felt the anger and fatigue of the last few months fall off me as if I was wearing a heavy suite of armour that had suddenly been shed.  I was myself again.

I don't know when medicine became about the 99213, med reconciliation, and meaningful use.  I choke on the complexity of the artificial system that we have gone to great lengths to construct.  We are expending all our strength and good will on useless bureaucratic minutia.

I almost forgot that as human beings our job is to be there for one another.  A friendly face.  A kind word.  The sharing of some minor wisdom.

As a profession, medicine offers this in spades.

Thursday, June 21, 2012


Being a married man, I rarely notice other women.  But today in line at the grocery store there was this strikingly attractive woman...wait, I'm getting ahead of myself.

A certain family member of mine has an issue with constipation.  I won't reveal her identity, but let's just say that she's less then four feet tall.  Thankfully, a few years back, we discovered Miralax..  In fact, the sigth of the white bottle with the purple top is enough to induce multiple family members to run to the bathroom.  In my household, all is good as long as the white powder is flowing into a certain little mouth.

The idea of running out of Miralax is enough to throw my family into mass hysteria.  Thus, from time to time, I get an anxious call from my wife telling me to stop on the way home from work.  Today was one of those days.  As I perused the pharmacy isle at the local grocery store, I eyed what I like to call "constipation corner".  Next to the super size box of white magic were various salves and ointments, fiber supplements, and laxatives.

As every good parent knows, first comes constipation and then hemorrhoids.  So not only did I buy two cases of Miralax, I helped myself to some Preparation H and tucks pads.  I carried my cart of treats over to the checkout lane and placed them on the conveyor absentmindedly.  Glancing up, I was unexpectedly confronted by this goddess like specimen of female beauty (glsfb).  I caught my breath and looked down embarrassingly at my grouping of of products.

Luckily, the glsfb was fumbling with her credit card and had no interest in what some shlumpy dad was buying for his daughter's constipation.  Her fumbling became contagious, and the cashier and  bagger stumbled to transition from one customer to the next.  By the time I payed for my bag of goodies, we all stared at eachother expectantly.  I had a receipt in hand, but no one could figure out what happened to my groceries.

It dawned on all of us at the same time.  My purchases had somehow ended up in the cart of the glsfb who was standing in line at the coffee counter across the isle.  I turned to the cashier like in the movies, my body in slow motion as the words sputtered out of my mouth.


But she had already jumped out from behind the counter and was approaching the glsfb.  I followed behind helplessly. 

Excuse me ma'am, we accidentaly placed another customer's groceries in your cart.

Like she had some type of superhuman radar, the glsfb grabbed my bag immediately from the other ten in her possesion.  She opened it and peered in.  At first, I imagined she saw the white bottles and was confused, but as her face changed I realized that she recognized the tucks pads and Preparation H.  She looked up at me and smiled before cautiously thrusting the bag in my direction.

I could feel the warmth rise in my face.  I imagined my skin had turned a lighter shade of crimson.  With my head down, I grabbed the bag, and mumbled the only thing that came to mind.

My grandmother will be so relieved!

I turned and walked a few steps to the door and exited the building.

A gentle breeze blew across my face and mitigated the oppressive glare of the mid afternoon sun.

Wednesday, June 20, 2012

Falling Short

My kids chatter in the back of the car.  Their miniature violins are tucked in the space between the seats.  It's a sunny June day in Evanston.  As my mind wanders I catch a flurry of students in black caps and gowns.  A sash of purple flutters in the light spring breeze adding flair to the traditional attire.  Northwestern prepares to graduate yet another class of college students.

The visual cue sets off a flurry of memories.  In high school we wore tuxedos with black pants and white jackets.  My college graduation took place in the famed University of Michigan football stadium.  And I myself donned the purple sash as I sauntered down the hallowed halls the day I dared to call myself "doctor" for the first time.

I often wonder why we look so forward to these events.  We rejoice in the act of finishing, in reaching the end.  But when I look back at my life, it was the beginning of the journey that always brought the most joy.  During those early stages my goals seemed so far away and impossible.  I filled my days reaching and my nights dreaming of what I could be.

I pictured myself a physician a million times before I became one.  I replayed a thousand scenarios in my head, each one ending with me rushing into the room to save the day.  When I graduated medical school, I still had to climb through residency.  A decade later, I have surpassed the mythic peak and look down for the first time instead of up.

My children struggle to carry their violins as they climb the steps to their class.  They are so young.  The possibilities in front of them are endless. 

I wish I could explain how important dreams are.   I would tell them to strive far ahead of their abilities.

We should all die with wishes unfulfilled.

If we are lucky we almost get there,

but always fall just a tad short.

Tuesday, June 19, 2012

Primary Care

At long last my chapbook of poetry, Primary Care, is going to print via The Lives You Touch Publications.  I am especially proud of the reviews (that can be viewed by following the chapbook link) by Ginger Moran and Alarie Tennille.  I am also most grateful to the publisher O.P.W. Fredericks for his kind words.

The chapbook is 17 poems and cost $15.  If you are interested in a copy please email me at grumetjordan(at) or leave a comment on this post with your email address.

Monday, June 18, 2012

Oh, The Patients You'll See!


Today is your day.

You're off to Great Places!

You're an attending on your way!

You have a stethoscope around your neck

And a prescription pad in your pocket

You know how to examine the oropharynx

And even the eye socket

You're on your own. And you know what you know.

And YOU are the guy who'll decide where to go.

You'll look at many practices. Look 'em over with care.

About some you will say, "I don't choose to go there."

With your head full of brains and your shoes full of feet,

you're too smart to go down any not-so-good street.

And you may not find any

except those that make you moan.

In that case, of course,

you'll start one on your own.

There's more freedom there

in the wide open air.

In private practice things can happen

and frequently do

to people as smart

and studious as you.

And when patients start to line up at your door,

don't worry. Don't stew.

Just remember what your learned in residency.

You'll do what your mentors would do.



You'll be on your way up!

You'll be seeing great pathology!

You'll walk in the footsteps of giants

And be brilliant without apology.

Others will lag behind, because you'll have the speed.

You'll pass the whole gang of consultants and you'll soon take the lead.

Wherever you practice, you'll be the best of the best.

Wherever you go, you will top all the rest.

Except when you don't

Because, sometimes, you won't.

I'm sorry to say so

but, sadly, it's true

Diagnostic hang-ups

can happen to you.

You can get all hung up

in a prickle-ly perch.

And your consultants will fly on.

You'll be left in a Lurch.

You'll come down from the Lurch

with an unpleasant bump.

And the chances are, then,

that you'll remain in a diagnostic Slump.

And when you're in a Slump,

you're not in for much fun.

Regaining the confidence in yourself

is not easily done.

You will come to a place where the text books are not marked.

Some pages are lighted. But mostly they're darked.

A place you couldn't diagnose a sprain of a hip or elbow

Do you dare wait it out? Do you dare consult ortho?

And IF you consult ortho, should you go with Dr. Kim or Dr. Right...

or maybe you should call rheum? Or, maybe, not quite?

Or get an Xray, you shouldn't decide blind?

Simple it's not, I'm afraid you will find,

for a mind-maker-upper to make up his mind.

You can get so confused

that you'll start to pace

down long winding hospital corridors at a break-necking pace

and grind on for miles across weirdish wild space,

headed, I fear, toward a most useless place.

The Fear Of Litigation Place...

...for people just waiting

to get sued.

Waiting for a suture to blow

or a lab to be lost, or blood to flow

or the mail to come, or the process server to show

or the phone to ring, or the patient to know

or waiting around for a Yes or a No

Everyone is just waiting.

Waiting for a fever to break

or waiting for the graft to take

or waiting around for the rash to flake

or waiting, perhaps, for a call from the patient's Uncle Jake

or a cough to clear, or a Better Break

or a trusting glance

or Another Chance.

Everyone is just waiting.


That's not for you!

Somehow you'll escape

all that waiting and staying.

You'll find the bright places

and forget what the lawyers are saying

With lab coat flip-flapping,

once more you'll ride high!

Ready for any illness under the sky.

Ready because you're that kind of a guy!

Oh, the patient's you'll see! There are diagnoses to make!

There are lungs to be auscultated. there are cultures to take.

And the magical things you can do with that brilliant mind

will make you the smartest doctor of all time

Fame! You'll be famous as famous can be,

with the whole wide world watching you give press conferences on TV.

Except when they don't.

Because, sometimes, they won't.

I'm afraid that some times

you'll be lonely too.

There are demons you can't cure

'cause the demons are inside you..

All Alone!

Whether you like it or not,

Alone will be something

A doctor is quite a lot.

And when you're a physician, there's a very good chance

you'll see things that scare you right out of your pants.

There are some, down the road between hither and yon,

that can scare you so much you won't want to go on.

But on you will go

though your mood be foul

On you will go

though the microbes prowl

On you will go

though the sickley howl

Onward up many

a frightening creek,

though your arms may get sore

and your stomach may be weak.

On and on you will hike

and I know you'll hike far

and face up to your dilemmas
whatever they are.

You'll get mixed up, of course,

as you already know.

You'll get mixed up

with many strange diseases as you go.

So be sure when you step.

Step with care and great tact

and remember that Life's

a Great Balancing Act.

Just never forget to be dexterous and deft.

And never mix up your right foot with your left.

And will you succeed?

Yes! You will, indeed!

(98 and 3/4 percent guaranteed.)



be your name Mayo, Mohs, or Mcbride

or any of the other giants we talk of with such great pride,

you're off to Great Places!

Today is your day!

Your patients are waiting.

So...get on your way!

Adapted from Dr. Seus, Oh! The places You'll Go!

Sunday, June 17, 2012

I'm No Saint

I want there to be full disclosure.

One may read this blog and start to think that I'm some kind of saint.  And admittedly,  there are those kumbaya moments where I'm hugging patients and high five-ing families.  But this is not the whole story.  There are also other moments when I am admonished for not being sufficiently attentive or castigated for my inabilities.

I've been fired.  Multiple times.  I've been told that I am a horrible doctor and threatened with malpractice.  I've been accused of not caring.  Every time I face these accusations, I try to honestly asses my own performance.  Sometimes I broadly proclaim my innocence, others I sheepishly apologize.  I am certainly not perfect.

As I have written before, the doctor-patient relationship is complicated.  Every day physicians battle a series of hurdles and  impairments.  Did they get enough sleep the night before?  Are they preoccupied with their spouses or children?  Are they feeling under the weather?

Add to this complexity the foibles of relationships and interactions.  Human beings misunderstand each other.  Certain personality types just don't mesh.  Mix in a sprinkling of fear and a dash of stress and what is left is a wick awaiting its flame.

So how do doctors and patients ever truly see each other?  I honestly have no idea.  I can, however, distill my own attempts into a few simple habits.

I begin each relationship with good intentions.

I think deeply about my patients in and out of the office.

I try to learn from each and every mistake.

And I am childishly optimistic in thinking that if I try hard enough,

I will improve over time.

Friday, June 15, 2012

Empathy Has Left The Building

As I write this post a frail sickly patient awaits anxiously by the phone for a call from her doctor that will never come.  Every day, countless people leave their physicians office angry, confused, and feeling abandoned.  Yet when I think back to my medical school class, I feel nothing but pride.  I couldn't imagine a more caring, conscientious group of young learners.

I remember my fellow residents working long hours.  They abandoned their families to sit at the side of a dying patient or catch up in the library.  We were entering a solemn profession, signing a covenant with humanity.  A decade later I struggle with the disconnect.  I don't know how to integrate who we were with who we have become.

Most physicians today feel like they are continuously under the gun.  Lambasted by insurance companies, petrified by medicare regulations, we struggle to follow a vague set of proclamations that carry dire consequences.  We cower in fear of malpractice attorneys, and bear the brunt of the emotional and physical turmoil of our patients.  We have mastered the art of duck and cover.

But the problem with always feeling like your dodging bullets, you lose the ability to help your patients do the same.  The poor swimmer who frantically treads to keep his head above water could never save the drowning man flopping in front of him.  Self preservation has ousted patient care in hierarchical primacy.

We all find different ways to deal with the stress.  Some escape in search of the next rainbow and pot of gold .  Many who remain physically in the field, have left emotionally.  The covenant is broken.

I can no more blame our reality on the public, than I can on those innocent medical students who enter the hospital with such hope.  Day after day our patients are getting the short end of the stick

Our nation as a whole, or our physicians must rise together and make a stand.  Barring such an occurrence, the systemic desensitization of this mighty profession will continue.

While the doctor will be available to see you,

empathy will have left the building

Thursday, June 14, 2012

Pretty Pretty Please


Pretty please.

Pretty, pretty please.

Don't just go to the emergency room.  Try me first.  OK, if death is imminent, call an ambulance.  But otherwise, I'm just a dial tone away.  And I am acquainted with the dizziness, chest pain, and swelling in your abdomen.  I read the results of your latest stress test.  I was there that day when the edema in your leg was a blood cot.

The doctor in the ER is kind and patient, but she doesn't know you.  She didn't stand by your side when your husband died or when you broke your leg.  She doesn't recognize that your eyes glaze over when your anxious or the wince you make when you're in pain.  But I do.

And things happen in emergency rooms.  Demented people get IV benadryl.  Renal patients gets NSAIDS.  Admission to a medical floor is a given if you are over the age of seventy.

Trust me, you want to avoid the hospital if possible.  Although you imagine yourself entombed in the warm bosom of safety, reality is much more frightening.  Resistant infections, medication errors, and hospital acquired delirium await you in every corner.

I want to protect you from these mishaps.  But once you hit the ER, I become superhero without a cape.  I lose my special powers.  My opinions and influence have no meaning there.  I have to wait till you arrive on the medical floor before I can declare your admission a waste of time, your arm pain muscular and not cardiac, and send you home.

Emergency rooms are good for emergencies.  Emergency doctors save lives.  But if your are dizzy, have a sinus infection, or swelling in the legs.  Call me first.

And we'll work through it together.

Wednesday, June 13, 2012

Medicine's Public Relations Problem

He prefers to be called Doctor.  Even when he is talking to other parents or teachers.  He thinks it's a matter of respect.  He started using the moniker in medical school.  He bragged to his friends that he always got the best seat when making dinner reservations.

He sometimes doesn't answer his pager.  He "left it in the car"or some other tired excuse.  Fellow physicians know that he is often unreachable. Patients wait by phones for hours hoping they will get a call back.  His answering service has finally stopped making excuses and simply pages him again.

He's late to clinic every morning.  Often after a long breakfast with his golf buddies, he strolls in an hour past his first appointment.  His patients wait in cold rooms scantily dressed in gowns as he peruses the latest stock quotes on his computer.  He instructs his staff to double and triple book.

He believes his title makes his opinion unassailable.  He often enhances the best case scenario.  He reserves end of life discussions till after the casket has long been buried under the ground.  He cuts patients off mid sentence.  He hands out narcotics and antibiotics freely, and never once considers his own fallibility.

He is absolutely the worst our profession has to offer.  Yet, we turn our heads and wipe our hands clean of the bloody mess that he has made of our credibility.

What we have in medicine is a PR problem.  If we expect the public to continue to remove our heads from the chopping block we are sadly mistaken.

It's time to rewrite the narrative.

Monday, June 11, 2012

This Nursing Home Gig

You couldn't blame Sonya for being unenthusiastic about her new job.  The last few months had been a whirlwind.  Danny's unexpected offer at the University had brought much joy but also much chaos.  Forced to quit her nursing job at an academic hospital, she searched frantically for a reasonable position in the new city.  But as moving day was approaching quickly, only one lousy opportunity lay at her door step. 

Sonya knew that Danny would be quite busy until he established himself.  Since the idea of not working and setting up house was deplorable, she begrudgingly accepted the spot at the nursing home.  She couldn't believe she was handing in her clinically superior role to become a mindless pill passer.  She braced herself to descend to the depths.  She would become a bottom feeder.

Her first few weeks on the job, Sonya found everything she was searching for.  She mentally checked off each category on her dreaded list: angry demented patients, nagging family members, bitter colleagues, and run down facilities to name a few.

But even in such deplorable conditions, a ray of light remained.  Sonya had watched as the administrator lovingly pushed a patient down to the cafeteria for coffee one morning.  She overhead the booming base of a fellow nurse singing to calm a delirious patient.  She watched as a certified nursing assistant fed a bed bound patient with exquisite care.

There were problems, like any nursing home, but there were also great moments of humanity.  Sonya found herself looking forward to seeing her patients every day.  She was especially fond of some of the custodial residents.  Overtime she was able to appreciate the strange beauty and quirkiness of life lived in a long term care facility.

One morning she arrived early to find that her favorite resident was doing poorly.  The message had come from the family to make her comfortable and to withdraw aggresive care.  Her only daughter was on a plane but would not arrive to early the next morning.  As Sonya's twelve hour shift came to an end, she peered in the room one last time before leaving.

She immediately recognized the breathing pattern and general stillness in the air.  Death was near.  Sonya grabbed her cell phone and texted Danny.  She wouldn't be home for dinner.  She pulled up a chair, sat quietly, and reached out for the old lifeless hand lying still on the bed.  She felt a faint squeeze.

No one under Sonya's care would ever have to die alone.  Her mind wandered.

This nursing home gig ended up to be much more fulfilling than she originally expected.

Saturday, June 9, 2012

Written In Crayon

Doc, what do you think happened?

I stood quietly next the police officer and coroner.  The first rays of sunlight unexpectedly pierced the darkness of the nursing home and illuminated the grisly scene. The patient laid perfectly still on the bed.  His rigid body was pale in comparison to the shockingly red blood that stained everything in the room.  The sheets, the floor, and the nurses call button were all but unrecognizable. 

I winced as I inspected the body.  There were no signs of loss from the mouth or rectum.  The greatest puddle surrounded the dialysis fistula.  I beckoned for the policeman to come over and take a look.  The coroner shook his head in confirmation as he spoke.

It must of been pretty quick, the nurse said it was quiet all evening.

I peeled the gloves off my hands and turned to leave the room.  As physicians, we are often shielded from the untidiness of death.  For the most part, our patients die in hospitals, clean and swaddled in the bosom of our medical machinations.

Of course we experience loss all the time, but until one is confronted with the sudden and incontrovertible proof, we allow denial to protect us from what is actually happening.


In various blog posts, I have written about the extinction of the modern day physician.  Although many agree with my viewpoint, there is a solid argument that I am being overly dramatic.  The detractors say that when you look at the statistics, there is no evidence off mass exodus.  Dissatisfaction may be slightly on the rise, but the physician work force is as strong as ever.

I think the error in such reasoning is that if one is looking for hemorrhage, they will not find it.  The flight of the American physician is much more subtle.  There is no rapid exsanguination, the marrow of a profession will deplete at a much more leisurely pace.

The evidence speaks for itself.  The red headed step children of the profession, the primary care doctors, are the first to leave the room.  Overworked and under payed, the next generation is avoiding this specialty like the plague.  No one denies that what once was respected as the core of medicine, will be handed over to non physician practitioners in the near future.  But as the economic whirlwind of our national debt becomes even more hungry, further cuts will be required to feed the beast.  The number of trainees aspiring to become cardiologists and general surgeons will decline as they become the next to go on the chopping block.

Recent evidence suggests that more physicians are choosing work/life balance over loyalty to the field.  Although the number of phsycians may remain constant, the actual physician hours are declining as a greater percentage of the workforce becomes part time.  Older physicians are retiring early, and younger physicians are choosing shift work and hospitalism over the drudgery of long term care.

And yes, doctors are cutting back clinical hours, taking administrative positions, and becoming consultants.

I believe the writing is already on the wall. 

You can't blame us if we decided to use crayon,

and not our own blood.

Thursday, June 7, 2012

Ditching Faith

I'm no biblical scholar. But I've always been mesmerized by the story of Abraham and Isaac.  As you may recall, God commands Abraham to bring his son Isaac to an altar on Mount Moriah and bind and sacrifice him.  At the last minute an Angel intervenes, and Abraham is directed to slaughter a ram instead.  It was an exercise to test Abraham's faith.

Only after cradling my own newborn in my arms, do I fully understand the impact of God's request.  To sacrifice one's offspring is the ultimate in brutality and repugnance.  I could no more willfully place my child in harms way than I could drown myself in a bathtub.  As the oxygen escapes my lungs my body will arise reflexively regardless of my own best intentions.

A parent will ditch faith a million times if it is required to protect her child.  This is our basic instinct.

The hardest part about being a physician is learning to cope with culpability.  In many ways my families are like Abraham.  They carry their loved one to my altar as if in sacrifice.  Their faith is strong and unwavering.  But unlike the God of the bible, I myself bow to an imperfect Deity.  My brain is frail and my judgement is prone to error.  The tremor of my hands is inconsistent.

Sometimes, however, I feel like I am Abraham.  And I am standing all alone on Mount Moriah with my beloved Isaac in my arms.  I bind him loosely and kneel as I place him on God's altar. 

I pray that this is more a test of my own durability and knowledge,

and less a sacrifice of the poor soul that lies in the ICU bed next to me.

Wednesday, June 6, 2012

More Is Better?

Trevor dropped a stack of papers on my desk as he waltzed into the office.  An athletic 45 year old, most of his care had been routine till now.  I placed  the  computer down and flipped through the pages.  The first, a stress echocardiogram, was normal.  The next was a lab report with a cholesterol panel, and the last was a consultation from a cardiologist.

I looked up dissapointedly.  Nothing bothers me more than when a patient gets a bunch of diagnostic testing without my knowing about it.  I waited quietly for an explanation.  Trevor spoke hurriedly to fill the void.

I got this flyer in the mail.

Apparently the mammoth university owned medical group sent out a mass mailing.  Trevor, who had a distant family history of coronary disease, responded positively to the simplistic questions on the front cover and called to make an appointment.  Presto!  A few days later he was sitting in front of a cardiologist.  Although he had a paucity of cardiac risk factors, there was this strange jaw pain (previously diagnosed TMJ) and this tingling in his left thumb (soon to be diagnosed carpal tunnel).  The cardiologist sent him for a stress echocardiogram (not a stress electorcardiogram which was the more appropriate test given the normal EKG).  He also checked a cholesterol panel which was marked as abnormal because Trevor's LDL was 120.  According to the cardiologists laboratory a normal LDL is no greater than 100 (my goal for non cardiac patients is usually 130-150).

Thankfully, Trevor had not filled the prescription for Lipitor that was called into his pharmacy.  He also hadn't yet made an appointment for a followup with the cardiologist.  I spent the rest of the appointment trying to undo the harm that had already been done.  I couldn't, however, unspend the thousand dollar bill that his insurance company had so dutifully paid.

We are headed for disaster!  Obamacare, with it's noble intentions, has already led to the mass proliferation of humongous hospital owned medical groups.  The downward pressure caused by increasing technology and reporting requirements will likely bankrupt the small practitioner.  What will be left is large, businessman driven, revenue generating health care. 

Are we ready for more is better?

Tuesday, June 5, 2012

Beware-Angry Rant

I stared at my desk incredulously, not a pen in sight.  In fact, I scoured the office up and down for minutes without luck.  Apparently, I wouldn't be able to write that all important script. One could conclude from this exercise that my office staff needs to better monitor our supply reserves.  Or, one could draw the conclusion that physicians are greedy, overpaid, untrustworthy scoundrels.

That's right, doctor's used to suck on the teet of big pharma by taking advantage of their logo bearing gifts of writing utensils.  Yet, some genius in the government decided that such influence was affecting prescribing patterns and unethical.  Unethical?

Wake up America!

Has anyone looked at the government lately.  How do you think congressman and presidential candidates stock their war chests.  Your telling me that pens are illegal yet lobbyists paying millions to our elected officials is OK.  It's not like it's changing their votes.  Ask John Edwards, what does he think all that money is being used for?  Do we really want these people defining our ethical norms?

Speaking of moral and ethical standards, how many physicians are getting million dollar bonuses for the holidays?  In fact, how many physicians are even making over a million dollars?  Maybe if we started to delve into derivatives and credit default swaps we would have a fighting chance.  But low and behold, investment bankers are still out there making a killing on misleading and bilking our community.  Even after the so called bailout the bonuses continue.  And were calling physicians unethical?

Maybe we should compare ourselves to the business tycoons that are keeping our nation strong.  Remember Enron?  Since when is outsourcing our jobs and offshoring their taxes good for our country?  No ethical problems there!

After all, physicians are a bunch of crooks.  We've heard of those rampant cardiologists who cath everything that moves.  Maybe even a few physicians have landed in jail.  Of course that never happens to politicians.  How many of them have ended up in jail in the last ten years for "minor" indiscretions.  I challenge you to find an ex governor from Illinois who hasn't spent time behind bars.

And then there are the lawyers.  Want to talk to a lawyer, take out your check book.  Want to hire a high profile attorney to handle your divorce or settle your law suit, take out a check book.  Win a large sum in a malpractice suit, don't forget to pay the pied piper first.  Physicians, on the other hand, get paid roughly the same fee no matter how experienced.  You want a doctors expert opinion?  Easy, make an appointment.  Spend as long as you like with them.  Consultations are affordable for just about everyone.

Physicians are the most highly trained, poorly paid professionals.  Who else answers phone calls in the middle of the night for free?  Who else suffers through a grueling apprenticeship, lasting years, and consuming almost every waking hour?  And who else stares down the triple barrel of death, disease, and litigation on a moment by moment basis?  Name one other profession where the likelihood of being sued for malpractice reaches almost 100 percent by the end of a career.

Any person who went into medicine for the money was a fool.  The impetus to joint this revered profession comes from the sincere hope to help society.  We have our bad apples.  But when taken as a whole, our moral and ethical accomplishments put most other professions to shame.

Stop making us the scapegoat!

Sunday, June 3, 2012

Intention And Social Media

I believe the road to success is paved with good intentions.  In fact, I think intention is underutilized in the realization of our ultimate goals.  Whether you dream of building a business, discovering a cure, or writing the next great American novel, you likely won't get very far without developing an appropriate sense of purpose.

Intent forms the nucleus for which a plan is built around.  It starts as an idea and spreads through conversations, emails, and proposals.  It affects who we interact with, what we read, and where we go.  Subconsciously intent tells those around us that we are serious and dedicated to an idea or concept. 

When we set off on a path with passion and vision, success can't help but befall us.  But the problem until recently with intention, is that it was just too parochial a concept.  Sure your family and friends knew all about your grand plans, but that CEO of that big corporation or the reporter on CNN were unlikely to be ensnared by your foresight.  We all, at some point, have become a victim of hyperlocalism.

Enter social media.  If intention is the gas that fuels your idea, then social media is the engine.  When concepts are generated and broadcast to a wider audience, intention galvanizes support, links like minded individuals, and puts opportunity at the forefront.  The obscure and unresourceful are now given a reasonable chance to explode on to the global scene.

It would be a mistake to say it's easy.  Developing a social media presence and cultivating your audience takes time and thought.  And above all else, creating superb content is a must if you want anyone to actually read what you are writing.

Saturday, June 2, 2012

Humility Is A Two Way Street

Shelly, ya betta get yoself to the ER!

The over sized bed shook in the trauma bay as Sheila continued to chatter about the circumstances that brought her into our care . The gynecology resident's legs trembled as his gloved hands held back layers of adipose tissue in an attempt to place the speculum.  As any good medical student, I stood behind him ready to anticipate his needs.  The mounds of fat formed a layered barrier which multiplied with each new excavation. 

After two more students were summoned to help retract, the resident was able to complete the vaginal exam.  He probed the outer wall and stumbled upon a large bulbourethral gland abscess.  Pus extruded as he palpated with his fingers.  The putrid stench of infection hit all our our nostrils at the same time.  Our heads turned in unison and our eyes squinted and mouths grimaced.  The ER resident watched from the doorway and snickered at our discomfort.

Within minutes Sheila's story, the morbidly obese woman with the pungent abscess, had spread among the residents and students in the hospital. Walking to the OR, a few classmates passed and giggled as they shot mock high fives in my direction.  The others on the teaching service scattered hoping they wouldn't be asked to assist the incision and drainage procedure taking place in the operating room.

A few minutes later, I gowned and gloved.  The scrub nurse waited at the door and placed a drop of wintergreen on my mask which overpowered the smells coming from Sheila who was unconscious on the operating table.  The surgical procedure lasted less than thirty minutes, the abscess was lanced and packed. 

By the time I sat down to write the operative note, it was well past midnight.  I halted at the nursing station trying to recall the appropriate nomenclature.  My efforts were interrupted by a nurse.  Sheila had spiked a fever and the phlebotomy team was unable to get blood cultures.  I looked around the corner.  All the residents were either in the OR or had gone to sleep.  I slowly sauntered over to the supply closet and withdrew the necessary supplies.

I worked on her for almost an hour.  Every time a good vein appeared it would role under my fingers and collapse before the precious flash of blood would appear.  At first Sheila was patient, but eventually the pokes elicited screams and finally prayers.

Oh Jesus help me!

The sweat rolled down my forehead and dropped onto her gown.  I finally was successful after using a large gauge needle on both femoral veins.  Sheila was exhausted.  I left the room with my tail tucked between my legs but triumphant.  I had secured the precious cultures. I placed the bottles on the table and reached over my left side for the labels resting on the counter.  Overworked and underslept, I lost balance and crashed onto the table.  The culture bottles bounced off my side and smashed onto the ground breaking into pieces.  I dropped onto my knees and watched the blood splash onto floor helplessly.

When I walked back into the room with a new tourniquet and syringe, Sheila almost jumped out of the bed and ran for the door.  My eyes averted while I explained what happened.  My usually confident voice sounded childlike and distant, apologetic.

Sheila lifted her hand from under the covers and unexpectedly grabbed mine.

Humility is a two way street, isn't it?

Like Dorothy finding out the truth about the wizard, all of the sudden I saw clearly.  Sheila knew about the snickers, and the wintergreen, and the disappearing housestaff.  She knew what people were thinking about her.  But this was her reality, and she needed our help.  She released my hand and I drew her blood once again.  This time I got it on the first stick.

I have thought of Sheila many times since that day.  Every time I get angry, disgusted, or annoyed by my patients, I see her smiling face. 

And I realize that sometimes they feel the same way about me.